Febrile neutropenia

D70

DESCRIPTION

Febrile neutropenia is conventionally defined as an absolute neutrophil count of <0.5 x 109/L with a temperature of greater than 38°C for >1 hour or a single temperature of 38.3°C, but any neutropaenic patient showing clinical signs of sepsis should be investigated.

Note:

  • This is a medical emergency as a minor infection may become very serious, these patients can rapidly develop features of severe sepsis (multi-organ failure and/or hypotension). It is crucial to monitor and treat patients for signs and symptoms of infection.
  • Cultures should be obtained for appropriate microbiological testing prior to empirical antimicrobial therapy. It is critical to recognise neutropenic fever early and to initiate empiric systemic antibacterial therapy promptly in order to avoid progression to a sepsis syndrome and possibly death.

LoEIII [11]

GENERAL MEASURES

Treat the underlying cause of neutropenia, if applicable.
Withdraw any medication that may cause neutropenia.
Consider removing central IV line. Once culture results are available, adjust treatment to the most appropriate narrow spectrum agent.

MEDICINE TREATMENT

For patients with febrile neutropenia within 48 hours of admission:

  • Ceftriaxone, IV, 1 g daily.

AND

  • Gentamicin, IV, 6 mg/kg daily (see GENTAMICIN, IV for guidance on prescribing).

If IV line, skin infection is suspected as the cause:

Add:

  • Vancomycin, IV, 30 mg/kg as a loading dose. Follow with 20 mg/kg/dose 12 hourly. (See VANCOMYCIN, IV for guidance on prescribing and monitoring).

If fever develops after 48 hours of admission:

(Choice of antibiotic will depend on local susceptibility patterns).

  • Carbapenem with activity against Pseudomonas, e.g.:
    • Meropenem, IV, 1 g 8 hourly

OR

Imipenem/cilastan, IV, 500/500 mg 6 hourly.

Note: Ertapenem is not recommended because it is not effective for Pseudomonas species, which are important pathogens in this setting.

OR

  • Piperacillin/tazobactam, IV, 4.5 g 8 hourly

AND

Amikacin, IV, 15 mg/kg daily. (See AMIKACIN, IV, for individual dosing and monitoring for response and toxicity).

LoEIII [12]

OR

  • Cefepime, IV, 2 g 12 hourly.

LoEIII [13]

If no response after 5–7 days: (In discussion with a Clinical Haematologist or Infectious Disease specialist).

ADD

  • Amphotericin B, IV, 1 mg/kg daily in dextrose 5 % over 4 hours.
    • Ensure adequate hydration to minimise nephrotoxicity. (See AMPHOTERICIN B, IV for preventing, monitoring and management of toxicity).

Duration of therapy:

  • If neutrophil count increases to >0.5 x 109 /L, continue for 2 days after fever has settled.
  • If neutrophil count remains ≤0.5 x 109 /L, continue for 7 days after fever has settled.

REFERRAL/CONSULTATION

All cases – consult with haematologist/oncologist.